<?php
/* @var $this FamilyHistoryController */
/* @var $model FamilyHistory */
/* @var $form CActiveForm */
?>

<div class="form">

<?php $form=$this->beginWidget('CActiveForm', array(
	'id'=>'family-history-form',
	'enableAjaxValidation'=>false,
)); ?>

	<p class="note">Fields with <span class="required">*</span> are required.</p>

	<?php echo $form->errorSummary($model); ?>

	<div class="row">
		<?php echo $form->labelEx($model,'blindness'); ?>
		<?php echo $form->textField($model,'blindness',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'blindness'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'blindness_relate'); ?>
		<?php echo $form->textField($model,'blindness_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'blindness_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'cataracts'); ?>
		<?php echo $form->textField($model,'cataracts',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'cataracts'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'cataracts_relate'); ?>
		<?php echo $form->textField($model,'cataracts_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'cataracts_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'crosseyes'); ?>
		<?php echo $form->textField($model,'crosseyes',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'crosseyes'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'croseyes_relate'); ?>
		<?php echo $form->textField($model,'croseyes_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'croseyes_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'galucoma'); ?>
		<?php echo $form->textField($model,'galucoma',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'galucoma'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'galucoma_relate'); ?>
		<?php echo $form->textField($model,'galucoma_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'galucoma_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'macular_degeneration'); ?>
		<?php echo $form->textField($model,'macular_degeneration',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'macular_degeneration'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'macula_degenerationr_relate'); ?>
		<?php echo $form->textField($model,'macula_degenerationr_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'macula_degenerationr_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'retinal_disease'); ?>
		<?php echo $form->textField($model,'retinal_disease',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'retinal_disease'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'retinal_disease_relate'); ?>
		<?php echo $form->textField($model,'retinal_disease_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'retinal_disease_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'arthiritis'); ?>
		<?php echo $form->textField($model,'arthiritis',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'arthiritis'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'arthiritis_relate'); ?>
		<?php echo $form->textField($model,'arthiritis_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'arthiritis_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'cancer'); ?>
		<?php echo $form->textField($model,'cancer',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'cancer'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'cancer_specify'); ?>
		<?php echo $form->textField($model,'cancer_specify',array('size'=>45,'maxlength'=>45)); ?>
		<?php echo $form->error($model,'cancer_specify'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'cancer_relate'); ?>
		<?php echo $form->textField($model,'cancer_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'cancer_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'diabetes'); ?>
		<?php echo $form->textField($model,'diabetes',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'diabetes'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'diabetes_relate'); ?>
		<?php echo $form->textField($model,'diabetes_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'diabetes_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'heart_disease'); ?>
		<?php echo $form->textField($model,'heart_disease',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'heart_disease'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'heart_relate'); ?>
		<?php echo $form->textField($model,'heart_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'heart_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'high_blood_pressure'); ?>
		<?php echo $form->textField($model,'high_blood_pressure',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'high_blood_pressure'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'high_blood_pressure_relate'); ?>
		<?php echo $form->textField($model,'high_blood_pressure_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'high_blood_pressure_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'kidney'); ?>
		<?php echo $form->textField($model,'kidney',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'kidney'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'kidney_relate'); ?>
		<?php echo $form->textField($model,'kidney_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'kidney_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'lupus'); ?>
		<?php echo $form->textField($model,'lupus',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'lupus'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'lupus_relate'); ?>
		<?php echo $form->textField($model,'lupus_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'lupus_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'thyroid'); ?>
		<?php echo $form->textField($model,'thyroid',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'thyroid'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'thyroid_relate'); ?>
		<?php echo $form->textField($model,'thyroid_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'thyroid_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'others'); ?>
		<?php echo $form->textField($model,'others',array('size'=>5,'maxlength'=>5)); ?>
		<?php echo $form->error($model,'others'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'others_specify'); ?>
		<?php echo $form->textField($model,'others_specify',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'others_specify'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'others_relate'); ?>
		<?php echo $form->textField($model,'others_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'others_relate'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'personalinfo_id'); ?>
		<?php echo $form->textField($model,'personalinfo_id'); ?>
		<?php echo $form->error($model,'personalinfo_id'); ?>
	</div>

	<div class="row buttons">
		<?php echo CHtml::submitButton($model->isNewRecord ? 'Create' : 'Save'); ?>
	</div>

<?php $this->endWidget(); ?>

</div><!-- form -->